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ALASKA WORKERS' COMPENSATION BOARD

P.O. Box 25512 Juneau, Alaska 99802-5512

GEORGE HERNANDEZ,
Employee,
Applicant,
v.
PROVIDENCE ALASKA MEDICAL CNTR,
Employer,
and
PROVIDENCE HEALTH SYSTEM - WASHINGTON,
Insurer,
Defendants. / )
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DECISION AND ORDER
AWCB Case Nos. 199704974, 199715460
AWCB Decision No. 01-0072
Filed with AWCB Anchorage, Alaska
April 13, 2001

We heard the employee’s claim for benefits on March 21, 2001 at Anchorage, Alaska. The employee represented himself. Attorney Constance Livsey represented the employer. Spanish interpreter Mary Osborne also appeared at the hearing. We closed the record at the conclusion of the hearing.

ISSUES

1.  Is the employee entitled to temporary total disability (TTD) benefits from March of 1999 through November of 1999 for his right knee condition?

2.  Is the employee entitled to TTD benefits from February 28, 2000 through April 25, 2000 for his right knee condition?

3.  Is the February 28, 2000 right knee surgery and follow-up care by Bret Mason, D.O. compensable?

4.  Did the employee suffer a compensable, work-related injury to his left knee?

SUMMARY OF THE EVIDENCE

On March 10, 1997, the employee filed a Report of Occupational Injury stating he strained his leg while working for the employer as a laundry assistant. The employee stated, “my right side leg muscles fell (sic) sore when I push the carts all the time for the past 3 months.” He had been working for the employer since November of 1994.[1] On March 12, 1997, the employee went to E. Hill Bryant, M.D., and complained of intermittent right knee pain since December 6, 1996. The employee stated his pain worsened when he pushed heavy carts at work, and he had been treating with Tylenol, Ben Gay and an elastic wrap, though he had been unable to work the past few days. He reported no previous history of a right knee injury. Upon examination, Dr. Bryant noted crepitus of the patella with movement and a “popping” below the patella with flexion and extension. Dr. Bryant diagnosed a right knee strain with tendonitis and prescribed Ibuprofen. In addition, Dr. Bryant released the employee back to work on March 17, 1997 with no pushing or pulling greater than twenty pounds, no bending, and no squatting.

Leslie Bryant, M.D., reexamined the employee on April 9, 1997. The employee wished to be released to full duty, as he had already been working at full capacity at work. He reported no significant pain at work, though he noted right knee soreness at the end of the day. Dr. Bryant diagnosed chondromalacia patella and released him to full-duty work. However, by April 28, 1997, the employee returned to Dr. Bryant and complained that pushing a heavy cart caused his right knee to become painful again. According to the employee, the employer informed him there was no job in laundry on weight restriction, though others in the laundry area did not have to push the carts. The employee was upset by the employer’s failure to provide alternative employment. Dr. Bryant once again released the employee to work with a weight restriction of fifty pounds and referred him to Declan Nolan, M.D., for further work-up.

On May 16, 1997, William Mayhall, M.D., evaluated the employee at the employer’s request. Dr. Mayhall suspected a right meniscal tear. On a more probable than not basis, Dr. Mayhall believed the cause of the employee’s knee condition was the work injury. Dr. Mayhall believed the employee could return to work with modifications for bending and heavy lifting. Moreover, an MRI taken of the right knee on June 19, 1999 revealed a “small, vertical tear of the apex of the middle third of the lateral meniscus.” The medial meniscus appeared normal.

Dr. Nolan treated the employee conservatively throughout June and July of 1999. Dr. Nolan also determined the chondromalacia patella, not the lateral meniscal tear, was the primary source of pain.[2] Moreover, on July 31, 1997, John Frost, M.D., evaluated the employee at Dr. Bryant’s request. Dr. Frost noted, “MRI of the knee does show a possible tear of the lateral meniscus. It is a small tear at the junction of the anterior middle thirds and it seems unlikely that even if it is present that it would be the cause of his fairly specific medial joint symptoms.” Dr. Frost went on to state, “I feel that he most likely has a medial plica syndrome…” Dr. Frost recommended the employee be restricted to very light desk work. If he failed to improve, Dr. Frost suggested arthroscopic procedure.

On September 10, 1997, Dr. Bryant issued a report and concluded the employee suffered from chondromalacia patella, possibly compounded by medial plica syndrome. According to Dr. Bryant, the MRI abnormality was not the cause of the employee’s symptoms. Dr. Bryant also determined the symptoms were work-related, and the employee should change to a job that does not include physical labor such as pushing 400-pound carts up ramps, bending, squatting and balancing.

Thereafter, in an October 10, 1997 chart note, Dr. Bryant noted the employee reported left knee pain.[3] On October 18, 1997, Thad Stanford, M.D., examined the employee at the employer’s request. The employee complained of pain in both knees, and Dr. Stanford noted the employee walked with a cane. After examining the employee, Dr. Stanford concluded the employee had complaints of pain without any objective evidence. Moreover, Dr. Stanford found no evidence in the record of a work injury to either the right or left knee. He could not confirm chondromalacia of either patella, and stated even if the employee suffered from chondromalacia of the patella, it was spontaneous in origin. Dr. Stanford diagnosed “Bilateral knee pain. Etiology undetermined.”

In addition, on December 15, 1997, Dr. Mayhall also examined the employee at the employer’s request. Dr. Mayhall stated:

It would appear to me that this gentleman apparently developed pain while pushing a heavy laundry cart, although he did not suffer a fall, perceive a twist or turn, it is my impression that a 144-pound man pushing a 600-pound cart, possibly up an incline, could increase pressure in the patellofemoral joint, and as well the medial joint line possibly injuring the knee. That is compressive forces and loads could cause enough friction between the retropatella surface in the femur, or the medial femoral condyle and tibia to cause severe irritation to the articular cartilage.

Dr. Mayhall continued to believe the employee had some type of “‘internal derangement’ that may be a retropatella chondromalacia-like syndrome.” Moreover he stated, “…I believe this gentleman probably did have an industrial ‘injury’ or the development of an (sic) condition such as anterior knee pain syndrome (chondromalacia) as a ‘result of his work.’”

Thereafter, the employee began treating with Glenn Ferris, M.D. At the hearing, the employee testified he went to Dr. Ferris on his own accord after Dr. Bryant became ill and cancelled his appointments. According to the employee, Dr. Bryant encouraged him to seek another physician. Dr. Frost reevaluated the employee on January 22, 1998, at Dr. Ferris’s request. The employee reported he had developed left knee pain after favoring his right knee. On examination of the left knee, Dr. Frost found the employee was “somewhat exaggerated with jumping and wincing with the examination.” Moreover, Dr. Frost ordered an x-ray of the left knee, which was read as normal.[4] Dr. Frost concluded:

I have the distinct impression that an arthroscopy would probably show negative or minimal findings. His pattern of pain location, symptom magnification, and lack of objective evidence of meniscus tear or other internal derangement leads me to be very reluctant to recommend a surgery on him. Frankly I do not (sic) what the etiology of the pain is but believe that an exploratory surgery is not indicated…I have explained that it is always possible that I am wrong and that he does, in fact, have an internal derangement; however, I would not be willing to recommend a surgery at this time…I do not find a direct relationship between the left knee pain and his job.[5]

The employee continued to see Dr. Ferris. An MRI of the left knee was performed and revealed a nearly normal knee. The only finding was the thinned, bowed appearance of the anterior cruciate ligament.[6] In a letter dated March 31, 1998, Dr. Ferris deferred to Dr. Frost’s opinion that the employee’s left knee condition was not work-related. In addition, on March 24, 1998, Dr. Ferris assessed a 4% permanent partial impairment (PPI) rating to the employee’s right knee. Dr. Ferris also referred the employee to David McGuire, M.D., for further evaluation.

On April 16, 1998, Dr. McGuire examined the employee and found he was disabled and in severe pain. He diagnosed a medial meniscus tear, and he suspected chondromalacia. Dr. McGuire also recommended arthroscopy because the pain was right on the jointline. On July 28, 1998, Dr. McGuire performed arthroscopic surgery and a partial lateral meniscectomy of the right knee. According to the operative report, there was no tear to the medial meniscus, though there was laxity of the ACL and synovitis of the inferior surface. Post-surgery, the employee experienced more pain than expected, as well as difficulty with range of motion. On August 17, 1998, Dr. McGuire noted, “He still limps with long walks.”[7] The employee then underwent a course of physical therapy. Physical therapy notes in October of 1998 show the employee continued to complain of medial knee pain with most activities.[8] Moreover, in November of 1998, Dr. McGuire found the employee still had limited range of motion of the right knee, though he commented, “I think this is a matter of rehab.” Dr. McGuire also noted continued complaints of medial pain, though there were no objective findings.[9]

On December 14, 1998, the employee complained of pain in cold weather, and Dr. McGuire determined the employee would be medically stable at six months post-surgery, or in five weeks. On February 15, 1999, Dr. McGuire assessed a 1% whole person PPI.[10]

The employee did not seek medical treatment again until June of 1999, when he saw Dr. McGuire for left knee pain. Dr. McGuire evaluated the employee and found the employee over reactive to pain. Dr. McGuire had no explanation for the employee’s left knee complaints and released him to work.[11] At the hearing, the employee testified Dr. McGuire told him he needed no further treatment and stated there was nothing else he could do for him. The only other medical record during this time is an MRI report of the right knee dated August 28, 1999. The MRI report revealed “thinning of the fibers of the anterior cruciate ligament,” as well as increased signal intensity consistent with small intrameniscal tears of the medial and lateral menisci.

The employee next sought treatment for his right knee with Bret Mason, D.O., on referral from Michael Todd, M.D., who treated the employee for carpal tunnel syndrome. According to the employee, his right knee was “never good” after the arthroscopic surgery in July of 1998.[12] On February 24, 2000, Dr. Mason recommended further arthroscopic procedure due to the employee’s continued pain and disability, as well as the August 1999 MRI findings. Dr. Mason noted photographs of the prior arthroscopic procedure suggested ACL laxity and contained a view of the patellofemoral articulation, but no medial structures.[13] On February 28, 2000, Dr. Mason performed arthroscopy of the right knee with “partial medial meniscectomy of the posterior horn and lateral meniscal shavings.” Dr. Mason also performed a limited synovectomy of the medial compartment and anterior patellofemoral articulation. His post-operative diagnoses included “small tears of the rim of the lateral meniscus” and “hypertrophic synovitis of medial compartment and anterior patellofemoral, especially medial synovial,” as well as a medial meniscus tear.[14]

On April 25, 2000, Dr. Mason examined the employee and determined he was doing very well post-surgery, fully weight bearing and with no apparent limp. The employee stated his pain was relieved and he was anxious to get back to work. Dr. Mason noted the employee did well in post-surgery therapy, had reached medical stability and could return to full-duty work with no restrictions. Moreover, Dr. Mason opined, “I feel more probable than not that the reason for his most recent surgery stems back to the injury he sustained at Providence in 1996.”[15]

Dr. Mayhall reevaluated the employee once again on February 9, 2001. Dr. Mayhall determined on a more probable than not basis the medial meniscus tear is not related to the work injury. Moreover, he found the 1997 injury at Providence was not a substantial factor in the need for arthroscopy in February of 2000. Dr. Mayhall went on to state:

In my opinion, the subsequent MRI scan done on the right knee on August 28, 1999, documents degenerative change in the meniscus, which I believe is idiopathic. Should the injury of 1996 have caused meniscal damage or degenerative change, it should have been present on the first MRI on a significant basis. Thus, in my opinion, this is idiopathic degenerative change, probably related to Mr. Hernandez’s age, relative varus of the knees (lack of the normal valgus positioning of approximately 5 to 7 degrees), and the aging process. The fact that he had a normal meniscus at arthroscopy in July 1998 and a tear in 2000 which was described as a horizontal flap tear (which is usually considered degenerative) indicates degenerative change to this tear. As opposed to that radial tears of the lateral meniscus have been described as traumatic.